Maternal Mortality and Severe Morbidity Associated With Low-Risk Planned Cesarean Delivery Versus Planned Vaginal Delivery at Term

Abstract

C esarean delivery rates in industrialized countries continue to rise. 1,2 The rates vary widely by country, health care facility and delivering physician, partly because of differing perceptions by health care providers as well as by pregnant women of its benefits and risks. [3][4][5][6][7] The relative safety of cesarean delivery and its perceived advantages relative to vaginal delivery have resulted in a change in the perceived risk-benefit ratio, which has accelerated acceptance. 1,[4][5][6][7][8][9][10][11][12] Indeed, a belief has become widespread that the risks of cesarean delivery for healthy women are so low as to make it a reasonable elective option for childbirth. 1,4,[12][13][14][15][16][17][18][19] Historically, most cesarean deliveries took place because of or in association with obstetrical complications or medical illness. However, rates of elective primary cesarean deliveries with no clear medical or obstetrical indication are rising dramatically. 1,5,6,[15][16][17][18][19][20] There is, therefore, a pressing need to assess the risks of maternal complications and death associated with elective cesarean delivery carried out in healthy women. Allen and colleagues 18 recently used the Nova Scotia Atlee Perinatal Database to compare outcomes of women whose cesarean deliveries were performed at term without labour and those with planned vaginal deliveries, but the relatively small sample size, the rarity of severe morbidity and absence of maternal deaths resulted in an incomplete picture. The main purpose of our study was to compare the risks of low-risk, elective cesarean delivery with those of planned vaginal delivery among healthy women at term. MethodsThe Canadian Institute for Health Information (CIHI) began collecting information on all admissions to Canada's acutecare hospitals in the early 1980s. CIHI's Discharge Abstract Database has been widely used for perinatal surveillance and research. 3,21,22 Data on all deliveries that took place from April 1, 1991 through March 31, 2005 were gathered for study except those occurring in the provinces of Quebec and Manitoba: complete information on these provinces was not contained in the database. The total number of in-hospital deliv-

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“…Caesarean section, especially those that are not medical justified, include a risk of maternal morbidity and mortality [30], as well as a risk of physical, emotional, and reproductive consequences for the mother and negative health outcomes for the child [31]. The growing rate of caesarean sections also has financial implications as the average cost of elective caesarean section is between 27-63% higher than vaginal delivery [32].…”

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“…Sheiner et al [27] reported a cesarean delivery rate of 25.5% in pregnancies after restrictive gastric bypass. Obstetricians attending post-bariatric surgery patients need to be aware of hemoglobin levels at the end of pregnancy since blood loss is known to be higher during cesarean delivery than during vaginal delivery [28,29].…”

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“…However, where patients are fully informed, restrictions on treatment cannot be based on the risks to the individuals themselves. After all, women are allowed to choose elective caesarean section despite the increases in risks of haemorrhage, hysterectomy, and cardiac arrest [44]. 13 Restrictions to individual liberty can generally be justified only if there are harms to third parties [28, p. 26].…”